This article was downloaded by: [Purdue University] On: 21 January 2015, At: 09:01 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of Community Health Nursing Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hchn20
Falling Between the Cracks: A Student Experience in Providing Home Care for Underserved Community Residing Elders Kristine Beyerman Alster & Jacqueline C. Keshian Published online: 07 Jun 2010.
To cite this article: Kristine Beyerman Alster & Jacqueline C. Keshian (1990) Falling Between the Cracks: A Student Experience in Providing Home Care for Underserved Community Residing Elders, Journal of Community Health Nursing, 7:1, 15-24, DOI: 10.1207/s15327655jchn0701_2 To link to this article: http://dx.doi.org/10.1207/s15327655jchn0701_2
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
JOURNAL OF COMMUNITY HEALTH NURSING, 1990, 7(1), 15-24 Copyright O 1990, Lawrence Erlbaum Associates, Inc.
Falling Between the Cracks: A Student Experience in Providing Home Care for Underserved Community Residing Elders
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Kristine Beyerman Alster, RN, EdD University of Massachusetts at Boston Jacqueline C . Keshian, RN, MSN Arlington Council on Aging INTRODUCTION
Nurses who work in the community are frequently concerned about elderly persons who could benefit from home nursing care, but who are not receiving such care for a variety of reasons. The local Council on Aging of Arlington, MA is interested in assisting the town's elderly residents to avoid having them "falling through the cracks" of the health-care system. The Council collaborates with the College of Nursing of the University of Massachusetts at Boston to provide home nursing support for clients who might otherwise not receive services. As part of a senior-level course in community-mental health nursing, students from the College make home visits to frail elderly individuals. THE COLLEGE OF NURSING
The University of Massachusetts at Boston is an urban institution that enrolls a large number of the so-called "nontraditional" student. The student body of the College of Nursing reflects the ethnic, age, and experiential diversity of the campus population. The average nursing student is 30 years of age at graduation. Not surprisingly, many students are employed, some work as many as 40 hr per week, many have children, and a number of students are single parents. In a typical class, men represent 10% of the group and ethnic minorities represent 15%. Approximately 10% of entering students hold a Bachelor of Science (BS) or a Bachelor of Arts (BA) degree in another field, with a few holding Master's degrees. THE COUNCIL ON AGING
Arlington, MA is a town with a population of 44,350 and is located 10 miles outside of Boston. It could be characterized as a largely White, middle-class commu---
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-
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Requests for reprints should be sent to Kristine Beyerman Alster, RN, EdD, College of Nursing, University of Massachusetts at Boston, Harbor Campus, Boston, MA 02125-3393.
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Social Service
Health Counseling
Support
Tax Assistance
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Council on Aging
&
Information & Referral
Energy
1
Nutrition
Transportat ion
Assistance
FIGURE 1 Services provided by the Arlington Council on Aging.
nity. Approximately 22% of the population is over age 60. Although the median household income is $20,598, data from the 1980 census indicates that for the 16town area of which Arlington is a part, 68.3% of persons over age 60 and living alone had incomes below $10,000, with more than one half of that group having incomes below $5,000. The Arlington Council on Aging provides services to all elderly town residents (Figure 1). Services include support groups, recreation and education, transportation, energy assistance, nutrition support, information and referral, tax assistance, social services, and health counseling. The Council employs one of the authors, Jacqueline C. Keshian, in the position of Health Nurse for the Elderly to provide services in the latter category. When the position was first established, the nurse's mandate was to provide health education and counseling to groups of elderly in the town. Thus, the focus was on population-based care. Collaboration with the College of Nursing allowed the Council to expand its health program to include some care to individuals as well. We believe that it is the bringing together of a flexible and progressive agency and a mature group of students that makes this enterprise possible. THE CLIENTS
Over the 5 years that the home nursing support program has been in operation, students have visited clients ranging from the "young old" to the "old old," men and women, and those with a variety of chronic and acute health problems. The largest number, however, share characteristics ascribed in the literature to Medicare-eligible home-care clients. That is, they are women, quite elderly, who live alone, and struggle with chronic health problems (Pasquale, 1988). Although not all of the clients match this description, there is one characteristic they do share: Each is marginal in terms of the home health services needed and received. Money is often as issue, but there are other reasons for clients' marginal status as well.
Falling Between the Cracks
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HEALTH NEEDS NOT COVERED BY MEDICARE Most clients in the program depend on Medicare to pay for health care; few have private insurance. But because Medicare provides reimbursement for only a limited number of skilled nursing visits, some individuals with long-term problems are left unassisted when coverage is discontinued. Indeed, it would appear that since the advent of Medicare's prospective payment system, chronically ill persons with ongoing needs for care have been competing for home-care monies with acutely ill clients who are being discharged from hospitals to convalesce at home (Auerbach, 1985; Ho, 1987). Medicare, in fact, was never intended to provide for long-term care (Koren, 1986). Nor does its narrow interpretation of "skilled nursing care" allow for the kind of nursing activities that many professionals believe are necessary in order to promote health and prevent illness in older persons (Smith, 1987). For example, Medicare regulations allow for reimbursement for the teaching activities of a nurse only if the teaching is specifically targeted to a problem identified by the physician who approves the care plan. Therefore, Medicare may not reimburse for a visit which includes teaching relative to a new problem or to prevention of problems. Nurses may also have difficulty establishing that the care in question ought. to be provided by a nurse, rather than by another worker. For instance, Medicare will provide reimbursement for care only if skilled observation and assessment are necessary in order to determine the client's status (Health Care Financing Administration, 1989). Some clients who require relatively simple measures of physical status, such as vital signs, may have psychosocial concerns that will not be readily apparent to an unskilled examiner, concerns that will not be elicited until the nurse has made several visits. Students in the home-support program carry out many sophisticated nursing interventions that would be denied reimbursement by Medicare. In one instance, a student visited a woman who had suffered a stroke which left her with a significant left-sided weakness. The client was becoming increasingly depressed, helpless, and reluctant to leave home. Student and client established a pattern of beginning each visit with a tub bath for the client. In the warm water, the woman relaxed-the only time of the day she felt good, she reported. Perched on the edge of the tub, the student helped the client to express her feelings, to grieve her losses, to identify her strengths, and to plan for the future. The relationship ended when the client left town to visit relatives-an expedition she planned and executed herself. Skilled nursing care? Yes. Medicare-reimburseable? No.
UNAWARE OF ELIGIBILITY FOR CrrHER SERVICES OR REFUSED OTHER SERVICES Some persons in the community are unaware of services for which they may be eligible. They may be relatively free of acute health problems that might bring them to
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Alster and Keshian
the attention of providers who can make referrals. Students occasionally encounter such individuals at health counseling clinics or through referrals from the Council's nurse, and can help them to obtain needed services. Other persons have refused available care because of pride, fear of incurring costs, denial of need, or suspicion of providers. Students in the home-support program have been remarkably successful in working with these clients. Because they are able to visit as often as twice a week for up to 14 weeks, students are often able to get past the barriers erected by fearful or wary clients. We have found that the trusting relationship that results is the sine qua non of the program. For example, two students visited a severely confused woman who was distressing her neighbors and landlord by her behavior. A caseworker for the self-neglect program of the state's Protective Services had been unable to effect a change in the woman's situation after 1%years of effort. Initially the woman was so distrustful that she refused to allow herself to be touched, even for blood pressure measurement. Eventually the nursing students were able to assist her with eating, bathing, and walking. They treated her for head lice and for a draining foot lesion. By working with the public health department, a physician, the client's nephew, and the client, they were able to facilitate her admission to a hospital, and from there to a nursing home. The client, who had initially refused help, eventually gained enough confidence in the students to accept the care she so desperately needed.
OVER INCOME FOR OTHER SERVICES Finally, some clients of the home-support program are in the peculiar position of having just a little too much money. The state-funded Home Care Program provides services to elders whose income does not exceed $13,500. Those persons with incomes exceeding this limit may find that out-of-pocket payments for similar services are more than they can afford. Even those who wish to pay privately may find that services are unavailable due to a serious shortage of workers in the home-care industry (Minuteman Home Care Corporation, 1988). Sources of Client Referrals
Referrals to the students are coordinated by the Council's Health Nurse for the Elderly, and come from sources throughout the community (Figure 2). Some are referrals from individuals who have identified a health concern. It is not uncommon for former clients to call seeking further assistance. Concerned neighbors, family, and clergy sometimes seek help on behalf of elderly persons. The students also engage in outreach through health counseling clinics held several times monthly at public places and at elderly housing sites throughout the town. Many referrals come from health-care workers and other professionals. Case managers from the area home-care agency sometimes work with students in order to add some home nursing support to the mix of services available to a client, as do
Falling Between the Cracks
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Sources of Client Referrals Self
V.N.A. Nurses
Outreach
Protective Service
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Family, Clergy Neighbors
a
Other Health Workers
i , / I C.O.A. Nurse
Students
FIGURE 2 Sources of client referrals.
state Protective Service workers. Visiting nurses closing cases occasionally ask us to work with persons who would benefit from continuing nursing monitoring. Discharge planners in the local hospital also identify potential clients for the program. A particularly memorable referral came to the health nurse from an ambulance driver. He had just brought a man home from a hospital, and was terribly worried about leaving him there alone. His concern was justified. When the health nurse and a student visited a few hours later, they found him alone, intoxicated, and incontinent of urine. The nurses arranged for his admission to another hospital for further care and alcohol detoxification.
Services Provided By Students Because the students are practicing in settings where a clinical instructor is not always physically present, we have special concerns about liability issues. Each student carries malpractice insurance, as do the instructor and agency nurse. At the beginning of the clinical experience, students receive clear directions regarding the support that they will receive, their responsibilities, and the limits of nursing practice in this setting. We are careful to emphasize that they will be learning and practicing the skills required by a generalist nurse, and will not be practicing the skills of a nurse practitioner, a physician, or other care providers. The use of nursing diagnoses in all nursing care plans reinforces the students' understanding of the domain of professional nursing. Although students may assist clients with treatments ordered by a physician, most of their activities are directed toward treating nursing diagnoses.
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Alster and Keshian
HEALTH ASSESSMENT Students participating in the program have completed a four-credit course in health assessment. They obtain a comprehensive health history from each client and perform a physical assessment. The data base is used to identify client strengths and health problems and to establish priorities of care. Students often identify significant concerns, such as unresolved grieving, hearing loss, and cognitive impairments.
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HEALTH COUNSELING AND TEACHING Because students visit each client once or twice a week, they focus largely on promoting self-care rather than on providing direct care. One rather unusual client "family" can provide several examples. Each semester, two students are assigned to visit a convent of elderly Episcopalian nuns. Originally, visits were conducted as a health counseling clinic, where blood pressures were measured and health concerns were monitored. As advancing age brought new health concerns, we deemed it advisable to see some of the sisters on an individual basis. Some of the issues addressed by the nuns and students have been: Sister A.-Impaired mobility related to osteoarthritis. Learned about medication and practiced range-of-motion exercises. Sister B.-Social isolation related to severe hearing loss. Was assisted to obtain hearing evaluation. Neglected dental care. Was assisted in locating dentist who could accommodate her neck tremor. Sister C.-Support offered in her long-term struggle with obesity. Depression following bilateral total knee replacements. Helped to restructure her work environment during convalescence.
PHYSICAL CARE Although the program does emphasize self-care, as just noted, students do provide physical care as necessary. They have changed dressings, assisted with hygiene, performed ear irrigations, administered medications, changed colostomy bags, and cleaned tracheostomies. In addition to providing direct care, students also teach clients and families to perform the activities required. At times, the client is able to resume self-care activities following a period of assistance.
EMOTIONAL SUPPORT AND LIFE REVIEW A series of losses associated with advancing age and personal circumstances has left many of our clients with a damaged sense of their own efficacy in the world. The resulting anxiety and depression leads some of these individuals to neglect themselves and their relationships with others, and to constrict their spheres of activity, sometimes to the point of becoming recluses. These situations, difficult as they may
Falling Between the Cracks
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Services Provided by Students Health Assessment
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a Health Counseling a Physical Care -& Emotional Support 8 Life Review -&-Obtain Other Services -& Consult With Other Providers FIGURE 3 Services provided by students.
be for students, do help them to experience the meaning of the "therapeutic relationship" described in their textbooks. In the context of this relationship, healing may occur as the client regains lost ego strength, and revives dormant skills. Some victories are small but intense. There was celebration at the Senior Center when a woman who had not left her home for years appeared for lunch one day on the arm of Phil, her nursing student. Even those clients who are coping well with the challenges of old age may find that engaging in reminiscence and life review is a helpful process. For many isolated elders, the visiting students may be the only person who can facilitate these activities. Helping a client with this final sorting out of one's life experiences is no less a nursing activity than teaching about medications (Figure 3).
OBTAIN OTHER SERVICES AND CONSULT WITH OTHER PROVIDERS Students in the home-nursing-support program act as liaisons between the clients and other health-care providers. They consult with physicians, pharmacists, physical therapists, and others in order to share and obtain information related to the clients' health status. When a student identifies a need for a client to use the services of another professional, he or she will make a referral. It is often necessary for the student to arrange for transportation as well. Sometimes, in-home care is necessary, as when a student arranged for a home-bound woman to be visited by a podiatrist.
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Alster and Keshian
Students also assist the persons that they care for to obtain other support services, such as meals-on-wheels or homemaker services.
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Student Involvement With Other Agencies We believe that students learning community health nursing need experience in both population-based and case-based nursing. Students at the Arlington Council on Aging have the opportunity to practice population-based care by participating in such activities as teaching projects and screening clinics. Recently, a group designed and presented a program on self-administration of medications. The same group assisted at a screening clinic for skin cancer. At times case-based care with clients in the home-support program leads to an opportunity to learn about the health needs of groups within the community. Such learning opportunities often arise when students become involved with other agencies on behalf of their clients. As mentioned previously, students may have contact with representatives of the Visiting Nurse Association (VNA), home-care corporation, and protective service agency. They may also become involved with the public housing authority, board of health, hospice, adult day care, hospitals, nursing homes, and Lifeline. Benefits of the Program To community and agency: Although the home care industry has experienced tremendous growth in recent years, many of the frail elderly remain without services (Spohn, Bergthold, & Estes, 1988). Indeed, it has been suggested that Medicare regulations act to systematically exclude many within this population from services (Poppleton, 1988). Nor are "free care" funds as available as they once were (Kilbane & Blacksin, 1988). At a time when budgets are being cut, a number of community agencies in the town of Arlington have been grateful for the direct care activities and the coordination of care provided by the University of Massachusetts nursing students. Each year, students make approximately 500 home visits. If these visits were costed out using the local VNA's per-visit charge of $75.00, the estimated dollar value of care provided would be approximately $37,500. As is so often the case in nursing, we find it difficult to estimate the savings associated with preventive health care. We simply do not know how many falls, self-medication errors and hospitalizations may have been averted by nursing interventions. And we do not know how to assign a dollar value to the alleviation of loneliness and the promotion of independence.
To students. Why select a Council on Aging as a clinical site for learning community mental health? Robertson (1988) pointed out that alternatives to traditional placements such as VNA's and health departments will need to be considered as funding problems result in decreased access to these agencies. We believe that there are positive reasons for selecting nontraditional placements as well. Our students enjoy an exceptional degree of autonomy. The elderly people with
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Falling Between the Cracks
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whom they work are indeed their clients. In consultation with the instructor and the health nurse, they establish the data base, and plan, implement and evaluate care. Although, the Council is not a traditional home health agency, students do provide care within the structure of the American Nurses Association's (1986) Standards of Home Health Nursing Practice. In a more traditional agency, students might be required to carry out a plan of care established by a staff nurse. Such a plan would, in many instances, be limited to those nursing activities that are reimbursable by Medicare. Furthermore, there is evidence in the literature that nurses in these settings are often distressed by a decrease in their own opportunities for autonomous decision making-the result of a change in agency focus from what is therapeutic to what is billable (Burbach, Schumacher, Lindsay, & Conrad, 1988: Meyers, 1988). We might be criticized for shielding students from the "real world" of practice. However, we find that our students do acquire an appreciation of the constraints on practice found in other settings. In part, this is facilitated by interactions with other providers and agencies. And in part, it occurs as a result of inductive reasoning. Several weeks into the semester, the question inevitably arises: "Who would care for these people if we did not?" When they discover that the answer is "Perhaps no one," students are left with a vivid understanding of the ways in which the healthcare system has failed their clients. It is our hope that these students will become nurses who first imagine, and then construct, a health-care system in which no elderly person will be allowed to "fall through the cracks."
REFERENCES American Nurses' Association. (1986). Standards of home health nursing practice. Kansas City, MO: Author. Auerbach, M. (1985). Changes in home health care delivery. Nursing Outlook, 33(6), 290-291. Burbach, C., Schumacher, K., Lindsay, L., & Conrad, M. (1988). How are we teaching home health nursing? American Journal of Nursing, 88(10), 1397, 1399. Health Care Financing Administration. (1989). Medicare Home Health Agency Manual (HCFA Publication 11, 04-89, Rev. 222, Retrieval Title: P 11 R 222). Washington, DC: Author. Ho, M. M. (1987). New horizons for home care: Responses to prospective payment. Public Health Nursing, 4(4), 2 19-223. Kilbane, K., & Blacksin, B. (1988). The demise of free care. Nursing Clinics of North America, 23(2), 435-442. Koren, M. J. (1986). Home care-Who cares? The New England Journal of Medicine, 314(14), 917920. Meyers, M. B. (1988). Home care nursing: A view from the field. Public Health Nursing, 5(2), 65-67. Minuteman Home Care Corporation. (1988). Minuteman Home Care Corpomtion area plan on aging. Lexington, MA: Author. Pasquale, D. K. (1988). Characteristics of Medicare-eligible home care clients. Public Health Nursing, 5(3), 129-134. Poppleton, L. A. (1988). Home health services: Organizational dilemmas. In Strategies for long term cam (National League for Nursing Publication No. 20-2231, pp. 253-262). New York: National League for Nursing. Robertson, J. E (1988). Benefits of using long-term care facilities for community health clinical experiences. Journal of Community Health Nursing, 5, 109-1 17.
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Smith, J. B. (1987). Home care is more than Medicare regs. American Journai of Nursing, 87(3), 305306. Spohn, P. H., Bergthold, L., & Estes, C. L. (1988). From cottages to condos: The expansion of the home health care industry under Medicare. Home Health Care Services Quarterly, 8(4), 25-55.
Journal of Community Health Nursing Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hchn20
Falling Between the Cracks: A Student Experience in Providing Home Care for Underserved Community Residing Elders Kristine Beyerman Alster & Jacqueline C. Keshian Published online: 07 Jun 2010.
To cite this article: Kristine Beyerman Alster & Jacqueline C. Keshian (1990) Falling Between the Cracks: A Student Experience in Providing Home Care for Underserved Community Residing Elders, Journal of Community Health Nursing, 7:1, 15-24, DOI: 10.1207/s15327655jchn0701_2 To link to this article: http://dx.doi.org/10.1207/s15327655jchn0701_2
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
JOURNAL OF COMMUNITY HEALTH NURSING, 1990, 7(1), 15-24 Copyright O 1990, Lawrence Erlbaum Associates, Inc.
Falling Between the Cracks: A Student Experience in Providing Home Care for Underserved Community Residing Elders
Downloaded by [Purdue University] at 09:01 21 January 2015
Kristine Beyerman Alster, RN, EdD University of Massachusetts at Boston Jacqueline C . Keshian, RN, MSN Arlington Council on Aging INTRODUCTION
Nurses who work in the community are frequently concerned about elderly persons who could benefit from home nursing care, but who are not receiving such care for a variety of reasons. The local Council on Aging of Arlington, MA is interested in assisting the town's elderly residents to avoid having them "falling through the cracks" of the health-care system. The Council collaborates with the College of Nursing of the University of Massachusetts at Boston to provide home nursing support for clients who might otherwise not receive services. As part of a senior-level course in community-mental health nursing, students from the College make home visits to frail elderly individuals. THE COLLEGE OF NURSING
The University of Massachusetts at Boston is an urban institution that enrolls a large number of the so-called "nontraditional" student. The student body of the College of Nursing reflects the ethnic, age, and experiential diversity of the campus population. The average nursing student is 30 years of age at graduation. Not surprisingly, many students are employed, some work as many as 40 hr per week, many have children, and a number of students are single parents. In a typical class, men represent 10% of the group and ethnic minorities represent 15%. Approximately 10% of entering students hold a Bachelor of Science (BS) or a Bachelor of Arts (BA) degree in another field, with a few holding Master's degrees. THE COUNCIL ON AGING
Arlington, MA is a town with a population of 44,350 and is located 10 miles outside of Boston. It could be characterized as a largely White, middle-class commu---
--
-
-
Requests for reprints should be sent to Kristine Beyerman Alster, RN, EdD, College of Nursing, University of Massachusetts at Boston, Harbor Campus, Boston, MA 02125-3393.
16
Alster and Keshian
Social Service
Health Counseling
Support
Tax Assistance
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Council on Aging
&
Information & Referral
Energy
1
Nutrition
Transportat ion
Assistance
FIGURE 1 Services provided by the Arlington Council on Aging.
nity. Approximately 22% of the population is over age 60. Although the median household income is $20,598, data from the 1980 census indicates that for the 16town area of which Arlington is a part, 68.3% of persons over age 60 and living alone had incomes below $10,000, with more than one half of that group having incomes below $5,000. The Arlington Council on Aging provides services to all elderly town residents (Figure 1). Services include support groups, recreation and education, transportation, energy assistance, nutrition support, information and referral, tax assistance, social services, and health counseling. The Council employs one of the authors, Jacqueline C. Keshian, in the position of Health Nurse for the Elderly to provide services in the latter category. When the position was first established, the nurse's mandate was to provide health education and counseling to groups of elderly in the town. Thus, the focus was on population-based care. Collaboration with the College of Nursing allowed the Council to expand its health program to include some care to individuals as well. We believe that it is the bringing together of a flexible and progressive agency and a mature group of students that makes this enterprise possible. THE CLIENTS
Over the 5 years that the home nursing support program has been in operation, students have visited clients ranging from the "young old" to the "old old," men and women, and those with a variety of chronic and acute health problems. The largest number, however, share characteristics ascribed in the literature to Medicare-eligible home-care clients. That is, they are women, quite elderly, who live alone, and struggle with chronic health problems (Pasquale, 1988). Although not all of the clients match this description, there is one characteristic they do share: Each is marginal in terms of the home health services needed and received. Money is often as issue, but there are other reasons for clients' marginal status as well.
Falling Between the Cracks
17
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HEALTH NEEDS NOT COVERED BY MEDICARE Most clients in the program depend on Medicare to pay for health care; few have private insurance. But because Medicare provides reimbursement for only a limited number of skilled nursing visits, some individuals with long-term problems are left unassisted when coverage is discontinued. Indeed, it would appear that since the advent of Medicare's prospective payment system, chronically ill persons with ongoing needs for care have been competing for home-care monies with acutely ill clients who are being discharged from hospitals to convalesce at home (Auerbach, 1985; Ho, 1987). Medicare, in fact, was never intended to provide for long-term care (Koren, 1986). Nor does its narrow interpretation of "skilled nursing care" allow for the kind of nursing activities that many professionals believe are necessary in order to promote health and prevent illness in older persons (Smith, 1987). For example, Medicare regulations allow for reimbursement for the teaching activities of a nurse only if the teaching is specifically targeted to a problem identified by the physician who approves the care plan. Therefore, Medicare may not reimburse for a visit which includes teaching relative to a new problem or to prevention of problems. Nurses may also have difficulty establishing that the care in question ought. to be provided by a nurse, rather than by another worker. For instance, Medicare will provide reimbursement for care only if skilled observation and assessment are necessary in order to determine the client's status (Health Care Financing Administration, 1989). Some clients who require relatively simple measures of physical status, such as vital signs, may have psychosocial concerns that will not be readily apparent to an unskilled examiner, concerns that will not be elicited until the nurse has made several visits. Students in the home-support program carry out many sophisticated nursing interventions that would be denied reimbursement by Medicare. In one instance, a student visited a woman who had suffered a stroke which left her with a significant left-sided weakness. The client was becoming increasingly depressed, helpless, and reluctant to leave home. Student and client established a pattern of beginning each visit with a tub bath for the client. In the warm water, the woman relaxed-the only time of the day she felt good, she reported. Perched on the edge of the tub, the student helped the client to express her feelings, to grieve her losses, to identify her strengths, and to plan for the future. The relationship ended when the client left town to visit relatives-an expedition she planned and executed herself. Skilled nursing care? Yes. Medicare-reimburseable? No.
UNAWARE OF ELIGIBILITY FOR CrrHER SERVICES OR REFUSED OTHER SERVICES Some persons in the community are unaware of services for which they may be eligible. They may be relatively free of acute health problems that might bring them to
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Alster and Keshian
the attention of providers who can make referrals. Students occasionally encounter such individuals at health counseling clinics or through referrals from the Council's nurse, and can help them to obtain needed services. Other persons have refused available care because of pride, fear of incurring costs, denial of need, or suspicion of providers. Students in the home-support program have been remarkably successful in working with these clients. Because they are able to visit as often as twice a week for up to 14 weeks, students are often able to get past the barriers erected by fearful or wary clients. We have found that the trusting relationship that results is the sine qua non of the program. For example, two students visited a severely confused woman who was distressing her neighbors and landlord by her behavior. A caseworker for the self-neglect program of the state's Protective Services had been unable to effect a change in the woman's situation after 1%years of effort. Initially the woman was so distrustful that she refused to allow herself to be touched, even for blood pressure measurement. Eventually the nursing students were able to assist her with eating, bathing, and walking. They treated her for head lice and for a draining foot lesion. By working with the public health department, a physician, the client's nephew, and the client, they were able to facilitate her admission to a hospital, and from there to a nursing home. The client, who had initially refused help, eventually gained enough confidence in the students to accept the care she so desperately needed.
OVER INCOME FOR OTHER SERVICES Finally, some clients of the home-support program are in the peculiar position of having just a little too much money. The state-funded Home Care Program provides services to elders whose income does not exceed $13,500. Those persons with incomes exceeding this limit may find that out-of-pocket payments for similar services are more than they can afford. Even those who wish to pay privately may find that services are unavailable due to a serious shortage of workers in the home-care industry (Minuteman Home Care Corporation, 1988). Sources of Client Referrals
Referrals to the students are coordinated by the Council's Health Nurse for the Elderly, and come from sources throughout the community (Figure 2). Some are referrals from individuals who have identified a health concern. It is not uncommon for former clients to call seeking further assistance. Concerned neighbors, family, and clergy sometimes seek help on behalf of elderly persons. The students also engage in outreach through health counseling clinics held several times monthly at public places and at elderly housing sites throughout the town. Many referrals come from health-care workers and other professionals. Case managers from the area home-care agency sometimes work with students in order to add some home nursing support to the mix of services available to a client, as do
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Sources of Client Referrals Self
V.N.A. Nurses
Outreach
Protective Service
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Family, Clergy Neighbors
a
Other Health Workers
i , / I C.O.A. Nurse
Students
FIGURE 2 Sources of client referrals.
state Protective Service workers. Visiting nurses closing cases occasionally ask us to work with persons who would benefit from continuing nursing monitoring. Discharge planners in the local hospital also identify potential clients for the program. A particularly memorable referral came to the health nurse from an ambulance driver. He had just brought a man home from a hospital, and was terribly worried about leaving him there alone. His concern was justified. When the health nurse and a student visited a few hours later, they found him alone, intoxicated, and incontinent of urine. The nurses arranged for his admission to another hospital for further care and alcohol detoxification.
Services Provided By Students Because the students are practicing in settings where a clinical instructor is not always physically present, we have special concerns about liability issues. Each student carries malpractice insurance, as do the instructor and agency nurse. At the beginning of the clinical experience, students receive clear directions regarding the support that they will receive, their responsibilities, and the limits of nursing practice in this setting. We are careful to emphasize that they will be learning and practicing the skills required by a generalist nurse, and will not be practicing the skills of a nurse practitioner, a physician, or other care providers. The use of nursing diagnoses in all nursing care plans reinforces the students' understanding of the domain of professional nursing. Although students may assist clients with treatments ordered by a physician, most of their activities are directed toward treating nursing diagnoses.
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HEALTH ASSESSMENT Students participating in the program have completed a four-credit course in health assessment. They obtain a comprehensive health history from each client and perform a physical assessment. The data base is used to identify client strengths and health problems and to establish priorities of care. Students often identify significant concerns, such as unresolved grieving, hearing loss, and cognitive impairments.
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HEALTH COUNSELING AND TEACHING Because students visit each client once or twice a week, they focus largely on promoting self-care rather than on providing direct care. One rather unusual client "family" can provide several examples. Each semester, two students are assigned to visit a convent of elderly Episcopalian nuns. Originally, visits were conducted as a health counseling clinic, where blood pressures were measured and health concerns were monitored. As advancing age brought new health concerns, we deemed it advisable to see some of the sisters on an individual basis. Some of the issues addressed by the nuns and students have been: Sister A.-Impaired mobility related to osteoarthritis. Learned about medication and practiced range-of-motion exercises. Sister B.-Social isolation related to severe hearing loss. Was assisted to obtain hearing evaluation. Neglected dental care. Was assisted in locating dentist who could accommodate her neck tremor. Sister C.-Support offered in her long-term struggle with obesity. Depression following bilateral total knee replacements. Helped to restructure her work environment during convalescence.
PHYSICAL CARE Although the program does emphasize self-care, as just noted, students do provide physical care as necessary. They have changed dressings, assisted with hygiene, performed ear irrigations, administered medications, changed colostomy bags, and cleaned tracheostomies. In addition to providing direct care, students also teach clients and families to perform the activities required. At times, the client is able to resume self-care activities following a period of assistance.
EMOTIONAL SUPPORT AND LIFE REVIEW A series of losses associated with advancing age and personal circumstances has left many of our clients with a damaged sense of their own efficacy in the world. The resulting anxiety and depression leads some of these individuals to neglect themselves and their relationships with others, and to constrict their spheres of activity, sometimes to the point of becoming recluses. These situations, difficult as they may
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Services Provided by Students Health Assessment
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a Health Counseling a Physical Care -& Emotional Support 8 Life Review -&-Obtain Other Services -& Consult With Other Providers FIGURE 3 Services provided by students.
be for students, do help them to experience the meaning of the "therapeutic relationship" described in their textbooks. In the context of this relationship, healing may occur as the client regains lost ego strength, and revives dormant skills. Some victories are small but intense. There was celebration at the Senior Center when a woman who had not left her home for years appeared for lunch one day on the arm of Phil, her nursing student. Even those clients who are coping well with the challenges of old age may find that engaging in reminiscence and life review is a helpful process. For many isolated elders, the visiting students may be the only person who can facilitate these activities. Helping a client with this final sorting out of one's life experiences is no less a nursing activity than teaching about medications (Figure 3).
OBTAIN OTHER SERVICES AND CONSULT WITH OTHER PROVIDERS Students in the home-nursing-support program act as liaisons between the clients and other health-care providers. They consult with physicians, pharmacists, physical therapists, and others in order to share and obtain information related to the clients' health status. When a student identifies a need for a client to use the services of another professional, he or she will make a referral. It is often necessary for the student to arrange for transportation as well. Sometimes, in-home care is necessary, as when a student arranged for a home-bound woman to be visited by a podiatrist.
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Students also assist the persons that they care for to obtain other support services, such as meals-on-wheels or homemaker services.
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Student Involvement With Other Agencies We believe that students learning community health nursing need experience in both population-based and case-based nursing. Students at the Arlington Council on Aging have the opportunity to practice population-based care by participating in such activities as teaching projects and screening clinics. Recently, a group designed and presented a program on self-administration of medications. The same group assisted at a screening clinic for skin cancer. At times case-based care with clients in the home-support program leads to an opportunity to learn about the health needs of groups within the community. Such learning opportunities often arise when students become involved with other agencies on behalf of their clients. As mentioned previously, students may have contact with representatives of the Visiting Nurse Association (VNA), home-care corporation, and protective service agency. They may also become involved with the public housing authority, board of health, hospice, adult day care, hospitals, nursing homes, and Lifeline. Benefits of the Program To community and agency: Although the home care industry has experienced tremendous growth in recent years, many of the frail elderly remain without services (Spohn, Bergthold, & Estes, 1988). Indeed, it has been suggested that Medicare regulations act to systematically exclude many within this population from services (Poppleton, 1988). Nor are "free care" funds as available as they once were (Kilbane & Blacksin, 1988). At a time when budgets are being cut, a number of community agencies in the town of Arlington have been grateful for the direct care activities and the coordination of care provided by the University of Massachusetts nursing students. Each year, students make approximately 500 home visits. If these visits were costed out using the local VNA's per-visit charge of $75.00, the estimated dollar value of care provided would be approximately $37,500. As is so often the case in nursing, we find it difficult to estimate the savings associated with preventive health care. We simply do not know how many falls, self-medication errors and hospitalizations may have been averted by nursing interventions. And we do not know how to assign a dollar value to the alleviation of loneliness and the promotion of independence.
To students. Why select a Council on Aging as a clinical site for learning community mental health? Robertson (1988) pointed out that alternatives to traditional placements such as VNA's and health departments will need to be considered as funding problems result in decreased access to these agencies. We believe that there are positive reasons for selecting nontraditional placements as well. Our students enjoy an exceptional degree of autonomy. The elderly people with
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whom they work are indeed their clients. In consultation with the instructor and the health nurse, they establish the data base, and plan, implement and evaluate care. Although, the Council is not a traditional home health agency, students do provide care within the structure of the American Nurses Association's (1986) Standards of Home Health Nursing Practice. In a more traditional agency, students might be required to carry out a plan of care established by a staff nurse. Such a plan would, in many instances, be limited to those nursing activities that are reimbursable by Medicare. Furthermore, there is evidence in the literature that nurses in these settings are often distressed by a decrease in their own opportunities for autonomous decision making-the result of a change in agency focus from what is therapeutic to what is billable (Burbach, Schumacher, Lindsay, & Conrad, 1988: Meyers, 1988). We might be criticized for shielding students from the "real world" of practice. However, we find that our students do acquire an appreciation of the constraints on practice found in other settings. In part, this is facilitated by interactions with other providers and agencies. And in part, it occurs as a result of inductive reasoning. Several weeks into the semester, the question inevitably arises: "Who would care for these people if we did not?" When they discover that the answer is "Perhaps no one," students are left with a vivid understanding of the ways in which the healthcare system has failed their clients. It is our hope that these students will become nurses who first imagine, and then construct, a health-care system in which no elderly person will be allowed to "fall through the cracks."
REFERENCES American Nurses' Association. (1986). Standards of home health nursing practice. Kansas City, MO: Author. Auerbach, M. (1985). Changes in home health care delivery. Nursing Outlook, 33(6), 290-291. Burbach, C., Schumacher, K., Lindsay, L., & Conrad, M. (1988). How are we teaching home health nursing? American Journal of Nursing, 88(10), 1397, 1399. Health Care Financing Administration. (1989). Medicare Home Health Agency Manual (HCFA Publication 11, 04-89, Rev. 222, Retrieval Title: P 11 R 222). Washington, DC: Author. Ho, M. M. (1987). New horizons for home care: Responses to prospective payment. Public Health Nursing, 4(4), 2 19-223. Kilbane, K., & Blacksin, B. (1988). The demise of free care. Nursing Clinics of North America, 23(2), 435-442. Koren, M. J. (1986). Home care-Who cares? The New England Journal of Medicine, 314(14), 917920. Meyers, M. B. (1988). Home care nursing: A view from the field. Public Health Nursing, 5(2), 65-67. Minuteman Home Care Corporation. (1988). Minuteman Home Care Corpomtion area plan on aging. Lexington, MA: Author. Pasquale, D. K. (1988). Characteristics of Medicare-eligible home care clients. Public Health Nursing, 5(3), 129-134. Poppleton, L. A. (1988). Home health services: Organizational dilemmas. In Strategies for long term cam (National League for Nursing Publication No. 20-2231, pp. 253-262). New York: National League for Nursing. Robertson, J. E (1988). Benefits of using long-term care facilities for community health clinical experiences. Journal of Community Health Nursing, 5, 109-1 17.
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Smith, J. B. (1987). Home care is more than Medicare regs. American Journai of Nursing, 87(3), 305306. Spohn, P. H., Bergthold, L., & Estes, C. L. (1988). From cottages to condos: The expansion of the home health care industry under Medicare. Home Health Care Services Quarterly, 8(4), 25-55.
